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A 78-year-old woman with bilateral fungal sinusitis, which resulted in right orbital apex syndrome, underwent endoscopic sinus surgery and optic nerve decompression. Two months after the operation, she complained of anxiety and insomnia. Head CT showed subdural hematoma-like effusion and burr hole drainage was conducted. The collected fluid was not hematoma, but bloody, xanthochromic effusion with no pathogenic bacteria. Ten days later, she underwent drainage and dural biopsy after craniotomy because of relapse of subdural hygroma and progression of hypertrophic pachymeningitis associated with aggravation of psychiatric symptoms. A sample of the dura mater showed dense fibrosis with thickening, and Pseudomonas aeruginosa (P. aeruginosa) was detected by culture. Although otitis or sinusitis secondary to P. aeruginosa infection has been reported as a leading cause of infectious pachymeningitis, psychiatric symptoms alone and concomitant refractory subdural hygroma are atypical and unreported manifestations. In patients with pachymeningitis and a history of transnasal endoscopic surgery, P. aeruginosa infection should be considered, irrespective of an atypical clinical course and negative blood or fluid culture. Additionally, dural biopsy might help in detection of pathogenic bacteria.

A case of subacute hypertrophic pachymeningitis caused by <i>Pseudomonas aeruginosa</i> infection presenting with subdural hygroma